Knowledge of genomic testing among early-stage breast cancer patients

Awareness of genomic testing among patients with breast cancer in Europe

PURPOSE

Genomic testing, involving expression profiling of tumour tissue, is a powerful tool for determining appropriate treatments for certain cancer patients. This study aimed to evaluate awareness of genomic testing in breast cancer patients in five European countries.

METHODS

The survey was initiated by Cancer Patients Europe and developed with patient associations, oncologists, and a psycho-oncologist. Participants were recruited via email and social media and completed a 42-question internet survey.

RESULTS

Of 1383 participants in eligible countries completing the survey, 566 women with current or previous HR+/HER2- breast cancer, potentially eligible for genomic testing, were analysed. 245 (43.3 %) were aged 50-59 years and 381 (67.3 %) had received higher education. 238 participants (42.1 %) had heard about genomic testing; 122 (21.6 %) were informed of their eligibility for testing, and 104 (18.4 %) were given reasons for the test. The majority (N = 479; 84.6 %) felt they lacked sufficient information to decide, and only 139 (24.6 %) opted for testing. Overall, 246 (43.5 %) wanted more information on additional testing and 234 (41.3 %) wanted more information on treatment options. The main information sources were medical professionals (N = 363; 64.1 %) and the internet (N = 351; 62.0 %). However, 398 participants (70.3 %) indicated that their healthcare professionals did not advise them on where to find more information.

CONCLUSIONS

This study highlights insufficient awareness of, and access to, genomic testing in breast cancer. Healthcare professionals need to improve communication with patients regarding genomic testing and involve them in shared decision-making. Likewise, patient associations have a role in providing clear information to patients.

Improving patient understanding of GEP test results (IMPARTER4): an RCT

ABSTRACT

Objective

Explaining gene expression profiling (GEP) test results to patients can be challenging. We examined the utility of two 8 min films about Oncotype DX and Prosigna to aid the knowledge and decision-making of women with early-stage oestrogen receptor positive (ER+) breast cancer.

Methods and analysis

Patients awaiting GEP test results completed an anxiety questionnaire and the intolerance of uncertainty scale (IUS) before randomisation and divided into Group A (standard verbal and/or written hospital information) or Group B (standard information plus GEP film). Prior to results, they were interviewed about their GEP test knowledge and how the recurrence risk helps determine treatment options. After the results consultation, participants answered two further questionnaires. Participating clinicians completed IUS scales and reported their satisfaction with the results discussions.

Results

230/251 patients completed the study (Group A (n=106) and Group B (n=124)). The total knowledge score was higher in Group B (estimated between groups mean difference of 2.5 (95% CI:1.7 to 3.4) p<0.001). Most treatment decisions adhered to recommended risk of recurrence thresholds, although patients with higher trait anxiety were more likely to make less apparently rational decisions OR=0.93 (95%CI 0.88 to 0.97) p=0.002 (163/230; 70.8% received ET alone; 65/230; 28% ET plus chemotherapy, and two sought second opinions). Clinicians reported slightly longer consultations for Group A participants who tended to ask more difficult and unexpected questions.

Conclusion

Patients who received standard verbal and written information plus film had increased knowledge about GEP tests compared with standard information alone.

Trial registration number

ISRCTN28497350.

A Prospective Questionnaire-Based Study Evaluating Genetic Literacy and Impact of Brief Educational Intervention Among Breast Cancer Patients in a Low- to Middle-Income Country

INTRODUCTION

A significant proportion of breast cancer cases are hereditary and are potentially preventable. However, adoption of the preventive measures remains a significant challenge, particularly because of to lack of knowledge and awareness in low- to middle-income countries.

METHODS

This prospective study conducted at a high-volume tertiary care cancer center in North India to assess the knowledge, awareness, and attitudes of female breast cancer patients and impact of a brief educational intervention. The study involved three phases: pre-interventional assessment, educational intervention, and post-interventional assessment utilizing a structured questionnaire.

RESULTS

The study involved 300 newly diagnosed breast cancer patients; 16.7% were familial. At the outset, 87.0% patients had low knowledge of risk factors, 90.3% about screening, and 32.7% about treatment. Awareness levels were low: 13.7% aware of familial risk and 2.7% of breast cancer genes. Affordability of genetic testing was low (15.2%), and interest in testing for self and family members was limited (32.0% and 26.3%). Following educational intervention, a significant positive percentage change was noticed in knowledge (risk factors: 12.8%, screening: 36.2%, treatment: 82%), awareness (familial risk: 66.7%, BRCA gene: 12.3%), and attitude (testing for self: 17.8%, family: 19.5%).

CONCLUSIONS

This study highlights the significant knowledge gaps among breast cancer patients regarding genetics. The educational intervention led to notable improvements in knowledge, awareness, and attitudes, underscoring the importance of tailored patient education in breast cancer care.

IMPARTER, Phase 1 of an intervention to improve patients' understanding of gene expression profiling tests in breast cancer

PURPOSE

To compare participants' knowledge about gene expression profiling (GEP) tests and recurrence risks after reading an information leaflet with that following viewing of an information film.

METHODS

Using a randomised cross-over design, at time-point one (T1), women aged 45-75 years without breast cancer either read leaflets or watched information films about Oncotype DX or Prosigna tests. Participants answered nine questions assessing knowledge (maximum score 18). Next-day information in the opposite modality was provided and knowledge re-assessed. Additional questions probed which format was easiest to understand, participants' preferences for film or leaflet and their reasons for these.

RESULTS

120 women participated (60 received OncotypeDX films and leaflets; 60 received the Prosigna versions). T1 mean knowledge scores were higher following film viewing (13.37) compared with that after reading leaflets (9.25) (mean difference 4.1; p < 0.0001; 95% CI 3.2, 5.0). When participants read leaflets first and subsequently viewed films, all increased their scores (mean + 6.08, from T1 of 9.25, p < 0.0001; 95% CI 5.44, 6.72). When films were viewed first, followed by leaflets, (36/60, 60%), participants' scores declined (mean-1.55 from T1 of 13.37, p < 0.001; 95% CI -2.32, -0.78). A majority of participants expressed preferences for the films (88/120, 73.3%) irrespective as to whether they described OncotypeDX or Prosigna. Reasons included the clarity, ease of understanding, visual material and reassuring voice-over.

CONCLUSION

Discussions between oncologists and patients about recurrence risk results can be challenging. Information leaflets may aid understanding but often employ complex language. Information films significantly improved knowledge and were preferred by participants.

Patient and public understanding of the concept of 'personalised medicine' in relation to cancer treatment: a systematic review

Personalised medicine (PM) is becoming increasingly integrated into standard clinical practice for treating numerous diseases, including cancer. Implementing PM into healthcare systems will only be successful with the acceptance and input of both patients' and public opinion. This review, therefore, aimed to identify both patients' and public understanding, and perceived benefits and concerns of PM in cancer treatment. A literature search was conducted using MEDLINE, EMBASE, PsycINFO and CINAHL databases. The eligibility criteria specified that papers must explore the public or patients' understanding of PM or pharmacogenomic (PGx) testing in relation to cancer treatment. Patients have a greater understanding of, and trust in, PM compared with members of the public, but often misunderstand how genomic testing in PM works. Key areas that can be targeted to inform future health literacy interventions include genetic literacy for the public and understanding of how PM testing and treatment works for patients.

Using Breast Cancer Gene Expression Signatures in Clinical Practice: Unsolved Issues, Ongoing Trials and Future Perspectives

The development of gene expression signatures since the early 2000's has offered standardized assays to evaluate the prognosis of early breast cancer. Five signatures are currently commercially available and recommended by several international guidelines to individualize adjuvant chemotherapy decisions in hormone receptors-positive/HER2-negative early breast cancer. However, many questions remain unanswered about their predictive ability, reproducibility and external validity in specific populations. They also represent a new hope to tailor (neo)adjuvant systemic treatment, adjuvant radiation therapy, hormone therapy duration and to identify a subset of patients who might benefit from CDK4/6 inhibitor adjuvant treatment. This review will highlight these particular issues, address the remaining questions and discuss the ongoing and future trials.

Relationship between genetic knowledge and familial communication of CRC risk and intent to communicate CRCP genetic information: insights from FamilyTalk eMERGE III

Successful translation of genetic information into patient-centered care and improved outcomes depends, at least in part, on patients' genetic knowledge. Although genetic knowledge is believed to be an important facilitator of familial communication of genetic risk information, empirical evidence of this association is lacking. We examined whether genetic knowledge was related to frequency of current familial communication about colorectal cancer and polyp (CRCP) risk, and future intention to share CRCP-related genomic test results with family members in a clinical sample of patients. We recruited 189 patients eligible for clinical CRCP sequencing to the eMERGE III FamilyTalk randomized controlled trial and surveyed them about genetic knowledge and familial communication at baseline. Participants were primarily Caucasian, 47% male, average age of 68 years, mostly well educated, and with high-income levels. Genetic knowledge was positively associated with future-intended familial communication of genetic information (odds ratio = 1.11, 95% confidence interval: 1.02-1.23), but not associated with current communication of CRC risk (β = 0.01, p = .58). Greater current communication of CRC risk was associated with better family functioning (β = 0.04, p = 8.2e-5). Participants' genetic knowledge in this study was minimally associated with their intended familial communication of genetic information. Although participants have good intentions of communication, family-level factors may hinder actual follow through of these intentions. Continued focus on improving proband's genetic knowledge coupled with interventions to overcome family-level barriers to communication may be needed to improve familial communication rates.

Effects of health literacy skills, educational attainment, and level of melanoma risk on responses to personalized genomic testing

OBJECTIVE

Few studies have examined how health literacy impacts responses to genetic information.

METHODS

We examined this issue among 145 English or Spanish-speaking adult primary care patients enrolled in a trial that offered testing for MC1R gene variants that confer moderately increased melanoma risk. We investigated whether health literacy skills, educational attainment, or melanoma risk were related to short-term cognitive and affective responses to genetic test results.

RESULTS

On average, participants found the test results to be highly believable and clear, with low levels of negative emotional responses and moderate levels of positive responses. In adjusted models, health literacy skills were significantly inversely associated with confusion (OR = 0.75, 95 % CI = 0.58, 0.96); those with higher education thought significantly less about their test results (β = -0.66), were less hopeful (β = -0.89), and had lower distress (β = -1.15). We also observed a significant interaction (p < .001) between health literacy and melanoma risk in affecting the frequency of thoughts about test results.

CONCLUSION

The findings indicate that health literacy skills may affect to what extent individuals elaborate cognitively on genetic information.

PRACTICE IMPLICATIONS

Patients with lower health literacy skills or education may need support in understanding genetic test results.

Question Prompt List to Support Patient-Provider Communication in the Use of the 21-Gene Recurrence Test: Feasibility, Acceptability, and Outcomes

PURPOSE

The 21-gene recurrence score (RS) assay is used to guide breast cancer treatment decisions but can be poorly understood by patients. We examined the effects of a question prompt list (QPL) on knowledge, distress, and decisional conflict related to genomic testing and treatment in early-stage breast cancer.

METHODS

We describe the feasibility and acceptability of the QPL and the impact of the QPL on knowledge, distress, and decisional conflict before and after the receipt of the QPL (MEND 2, N = 65). We also compared distress and decisional conflict between women who received the QPL (MEND 2, N = 65) and a comparable group of women who did not receive the QPL who participated in an earlier observational study within the same clinics (MEND 1, N = 136).

RESULTS

MEND 2 participants indicated high acceptability and feasibility using the QPL. Knowledge increased post-QPL (P < .01) but did not decrease distress. Decisional conflict was lower among women in MEND 2 compared with those in MEND 1 (P < .01), with no statistically significant differences in distress.

CONCLUSION

The findings suggest that the QPL is feasible, acceptable, can improve knowledge and decrease decisional conflict in the large group of women deciding treatment while integrating RS test results.

Engaging Patients in Precision Oncology: Development and Usability of a Web-Based Patient-Facing Genomic Sequencing Report

PURPOSE

Evidence-based somatic and germline sequencing has transformed cancer care and improves patient outcomes. However, patients' low genetic literacy and misunderstanding of their own genomic results poses a threat to the realization of precision oncology. To optimize patient genomic comprehension, we developed a Web-based, patient-directed, genomic sequencing education and return-of-results tool, HOPE-Genomics.

METHODS

The HOPE-Genomics prototype included somatic and germline sequencing results, embedded multimedia genomic education, and interactive features (eg, request for genetic counseling). Between January and April 2018, we elicited feedback on tool usability and comprehensiveness through participant surveys, 4 focus groups of patients with cancer and their family members, and 3 provider focus groups (comprising 8 patients, 5 family members, and 19 providers).

RESULTS

We identified themes in patient/family tool-related responses, including the desire to view a patient-friendly report, a desire to receive multiple types of genomic information (eg, prognostic and uncertain), high acceptability of report content, and interest in tool-enabled access to genetic counseling. Major themes from the clinician focus groups included believing the tool could help patients formulate questions and facilitate patients' communication of results to family members. However, there were diverse responses from all participants in terms of tool implementation (ie, timing and nature of report release). Some participants preferred report release before meeting with the provider, and others preferred it during the appointment. Additionally, some clinicians were concerned about providing prognostic and treatment information through the tool.

CONCLUSION

There was high acceptability and interest from patients, family members, and providers in a patient-directed genomics report. Future work will determine whether direct-to-patient reporting of genomic results improves patient knowledge, care engagement, and compliance with genomically guided interventions.

Psychosocial and behavioral outcomes of genomic testing in cancer: a systematic review

Psychosocial and behavioral outcomes of genetic testing in oncology are well known, however, it is unclear how these findings will generalize to more complex genomic testing. The aim of this systematic review was to assess the psychosocial and behavioral outcomes of cancer genomic testing. Studies were selected for inclusion if they were published from January 2003 to January 2017 and addressed psychological and behavioral outcomes of cancer genomic testing in adults. A review of four databases identified 9620 abstracts, with 22 publications meeting the inclusion criteria. Of the included articles, 11 studies reported on outcomes of germline testing, with three articles assessing panel testing and eight SNP testing. No studies assessed the outcomes of WGS or WES. Eleven articles assessed the outcomes of somatic testing, including testing for cancer prognosis and for personalized therapies. Studies were biased toward breast cancer and Caucasian women with high education and socioeconomic status. While studies demonstrated limited adverse psychological outcomes associated with genomic testing, a lack of consistency in psychosocial measures precluded any meta-analysis. Changes in health behavior following positive results were limited, and in some cases risk perception was not altered following genomic testing. There is limited evidence of adverse psychosocial outcomes and changes in health behavior following genomic testing to assess cancer risk. Findings from this review highlight the need for longitudinal research with superior methodological and theoretical design.

Multilevel Influences on Patient-Oncologist Communication about Genomic Test Results: Oncologist Perspectives

Thousands of women with early-stage breast cancer receive gene-expression profile (GEP) tests to guide chemotherapy decisions. However, many patients report a poor understanding of how their test results inform treatment decision-making. We applied models of patient-centered communication and informed decision-making to assess which variables oncologists' perceive as most influential to effective communication with their patients about GEP results and intervention modalities and approaches that could support more effective conversations about treatment decisions in routine clinical care. Medical oncologists who were part of a practice group in the mid-Atlantic US completed an online, cross-sectional survey in 2016. These data were merged with de-identified electronic patient and practice data. Of the 83 oncologists contacted, 29 completed the survey (35% response rate, representing 52% of the test-eligible patients in the practice network). There were no significant differences between survey responders and nonresponders. Oncologists reported patient-related variables as most influential, including performance status (65.5%), pretesting preferences for chemotherapy (55.2%), and comprehension of complex test results (55.2%). Oncologists endorsed their experience with testing (58.6%) and their own confidence in using the test results (48.3%) as influential as well. They indicated that a clinical decision support tool incorporating patient comorbidities, age, and potential benefits from chemotherapy would support their own practice and that they could share these results and other means of communication support using print materials (79.3%) with their patients in clinic (72.4%). These preferred intervention characteristics could be integrated into routine care, ultimately facilitating more effective communication about genomic testing (such as GEP) and its role in treatment selection.

The impact of media type on shared decision processes in third-age populations

PURPOSE

To examine the relationship between the media, through which medical information was made available (e.g. digital versus printed), and the patients' desire to play an active part in a medical decision in an SDM or an ISDM-based process. The goal of this research was to expand knowledge concerning social and personal factors that affect and explain patients' willingness to participate in the process.

METHODS

A questionnaire was distributed in this empirical study of 103 third-age participants. A theoretical model formed the basis for the study and utilized a variety of factors from technology acceptance, as well as personal and environmental influences to investigate the likelihood of subjects preferring a certain decision-making approach. The research population included men and women aged 65 or older who resided in five assisted living facilities in Israel. The sample was split randomly into 2 groups. One group used digital information and the other print. A path analysis was conducted, using Structural Equation Modelling (SEM) in AMOS SPSS, to determine the influence of the information mode of presentation on the patient's choice of the SDM or ISDM model.

RESULTS

When digital media was accessible, the information's perceived usefulness (PU) led participants to choose an ISDM-based process; this was not true with printed information. When information was available online, higher self-efficacy (SE) led participants to prefer an SDM-based process. When the information was available in print, a direct positive influence was found on the participant's choice of SDM, while a direct negative influence was found on their choice of an ISDM-based process. PU was found to be affected by external peer influences, particularly when resources were made available in print. This meant that digital resources tended to be accepted at face value more readily. Cognitive absorption had a positive effect on the research variables only when the information was available digitally. The findings suggest the use of digital information may be related to cognitive functions of older adults, since the use of digital technology and information requires more cognitive effort.

CONCLUSIONS

The study illustrates factors that make patients choose SDM or ISDM-based processes in third-age populations. In general, the results suggest that, even though a physician may attempt to place the patient in the center of the decision process, printed information does not empower the patient in the same way that digital resources do. This may have wider ramifications if the patient does not buy into the treatment plan is and becomes less motivated to be compliant with the treatment. Another key contribution of this research is to identify processes that reflect information assessment and adoptions, and the behaviors related to medical decision making, both as a model and as a process. This study suggests what health care professionals should expect to see as the transition to more digital information sources becomes the norm among the elderly population. Future research is needed to examine this model under different conditions, and to check for other variables and mechanisms perceived as mediators in the choice of SDM or ISDM processes.

Multigene expression profile testing in breast cancer: is there a role for family physicians?

BACKGROUND

Family physicians (fps) play a role in aspects of personalized medicine in cancer, including assessment of increased risk because of family history. Little is known about the potential role of fps in supporting cancer patients who undergo tumour gene expression profile (gep) testing.

METHODS

We conducted a mixed-methods study with qualitative and quantitative components. Qualitative data from focus groups and interviews with fps and cancer specialists about the role of fps in breast cancer gep testing were obtained during studies conducted within the pan-Canadian canimpact research program. We determined the number of visits by breast cancer patients to a fp between the first medical oncology visit and the start of chemotherapy, a period when patients might be considering results of gep testing.

RESULTS

The fps and cancer specialists felt that ordering gep tests and explaining the results was the role of the oncologist. A new fp role was identified relating to the fp-patient relationship: supporting patients in making adjuvant therapy decisions informed by gep tests by considering the patient's comorbid conditions, social situation, and preferences. Lack of fp knowledge and resources, and challenges in fp-oncologist communication were seen as significant barriers to that role. Between 28% and 38% of patients visited a fp between the first oncology visit and the start of chemotherapy.

CONCLUSIONS

Our findings suggest an emerging role for fps in supporting patients who are making adjuvant treatment decisions after receiving the results of gep testing. For success in this new role, education and point-of-care tools, together with more effective communication strategies between fps and oncologists, are needed.

Development and Validation of a Genomic Knowledge Scale to Advance Informed Decision Making Research in Genomic Sequencing

Background

This study evaluated the psychometric properties of a new, comprehensive measure of knowledge about genomic sequencing, the University of North Carolina Genomic Knowledge Scale (UNC-GKS).

Methods

The UNC-GKS assesses knowledge in four domains thought to be critical for informed decision making about genomic sequencing. The scale was validated using classical test theory and item response theory in 286 adult patients and 132 parents of pediatric patients undergoing diagnostic whole exome sequencing (WES) in the NCGENES study.

Results

The UNC-GKS assessed a single underlying construct (genomic knowledge) with good internal reliability (Cronbach's alpha = 0.90). Scores were most informative (able to discriminate between individuals with different levels of genomic knowledge) at one standard deviation above the scale mean or lower, a range that included most participants. Convergent validity was supported by associations with health literacy and numeracy (rs=0.41-0.46). The scale functioned well across subgroups differing in sex, race/ethnicity, education, and English proficiency.

Discussion

Findings supported the promise of the UNC-GKS as a valid and reliable measure of genomic knowledge among people facing complex decisions about WES and comparable sequencing methods. It is neither disease- nor population-specific, and it functioned well across important subgroups, making it usable in diverse populations.

Patient-Centered Communication for Discussing Oncotype DX Testing

Oncotype DX testing (ODX), a tumor gene expression test, may improve breast cancer care, however, communicating results remains challenging. We identified patient-centered communication strategies/gaps for discussing ODX results. We applied a patient-centered communication framework to analyze qualitative interviews with oncologists about how they communicate about ODX with patients, using template analysis in Atlas.ti. Overall, providers discussed four patient-centered communication domains: exchanging information, assessing uncertainty, making decisions and cross-cutting themes. Providers did not report discussing emotional aspects of managing uncertainty, assessing decision-making preferences, and evaluating decisions. A patient-centered approach may be a model for communicating about tumor gene expression tests.

Empirical relationships between numeracy and treatment decision making: A scoping review of the literature

OBJECTIVES

To determine what is known from the existing literature about empirical relationships between numeracy and the three stages of the treatment decision making process (information exchange, deliberation, and deciding on the treatment to implement). We also examined if, and how, numeracy was mentioned in relation to health literacy.

METHODS

A search of four databases returned 2772 records. After de-duplication and three levels of relevance screening, 38 primary studies were included in this review.

RESULTS

Relationships between numeracy and the information exchange stage have received greater attention than relationships between numeracy and the deliberation and deciding on the treatment to implement stages. The lack of overlap in the empirical relationships examined in studies, the measure(s) of numeracy used, and the characteristics of study populations, made findings difficult to compare. Multiple knowledge gaps and measurement-related problems were identified. Numeracy and health literacy have largely been treated as separate concepts.

CONCLUSION

More research is needed to better understand the importance of numeracy and health literacy to treatment decision making.

PRACTICE IMPLICATIONS

Decision aids designed for patients with different levels of health literacy may not meet the needs of patients with different levels of numeracy. The numeracy skills of health professionals require attention.

Patient knowledge and information-seeking about personalized cancer therapy

BACKGROUND

Understanding patients' knowledge and prior information-seeking regarding personalized cancer therapy (PCT) may inform future patient information systems, consent for molecular testing and PCT protocols. We evaluated breast cancer patients' knowledge and information-seeking behaviors regarding PCT.

METHODS

Newly registered female breast cancer patients (n=100) at a comprehensive cancer center completed a self-administered questionnaire prior to their first clinic visit.

RESULTS

Knowledge regarding cancer genetics and PCT was moderate (mean 8.7±3.8 questions correct out of 16). A minority of patients (27%) indicated that they had sought information regarding PCT. Higher education (p=0.009) and income levels (p=0.04) were associated with higher knowledge scores and with seeking PCT information (p=0.04). Knowledge was not associated with willingness to participate in PCT research.

CONCLUSION

Educational background and financial status impact patient knowledge as well as information-seeking behavior. For most patients, clinicians are likely to be patients' initial source of information about PCT. Understanding patients' knowledge deficits at presentation may help inform patient education efforts.

The value of personalizing medicine: medical oncologists' views on gene expression profiling in breast cancer treatment

OBJECTIVES

Guidelines recommend gene-expression profiling (GEP) tests to identify early-stage breast cancer patients who may benefit from chemotherapy. However, variation exists in oncologists' use of GEP. We explored medical oncologists' views of GEP tests and factors impacting its use in clinical practice.

METHODS

We used a qualitative design, comprising telephone interviews with medical oncologists (n = 14; 10 academic, 4 in the community) recruited through oncology clinics, professional advertisements, and referrals. Interviews were analyzed for anticipated and emergent themes using the constant comparative method including searches for disconfirming evidence.

RESULTS

Some oncologists considered GEP to be a tool that enhanced confidence in their established approach to risk assessments, whereas others described it as "critical" to resolving their uncertainty about whether to recommend chemotherapy. Some community oncologists also valued the test in interpreting what they considered variable practice and accuracy across pathology reports and testing facilities. However, concerns were also raised about GEP's cost, overuse, inappropriate use, and over-reliance on the results within the medical community. In addition, although many oncologists said it was simple to explain the test to patients, paradoxically, they remained uncertain about patients' understanding of the test results and their treatment implications.

CONCLUSION

Oncologists valued the test as a treatment-decision support tool despite their concerns about its cost, over-reliance, overuse, and inappropriate use by other oncologists, as well as patients' limited understanding of GEP. The results identify a need for decision aids to support patients' understanding and clinical practice guidelines to facilitate standardized use of the test.

Patterns of 21-gene assay testing and chemotherapy use in black and white breast cancer patients

BACKGROUND

In women with early stage, hormone receptor (HR)-positive (HR(+)) breast cancer, the 21-gene recurrence score (RS) assay quantifies recurrence risk and predicts chemotherapy responsiveness. Recent data suggest that not all women with early-stage, HR(+) disease receive this testing. We examined sociodemographic, clinical, and attitudinal factors associated with RS testing receipt and the RS testing effect on chemotherapy use in black and white patients.

PATIENTS AND METHODS

Women with newly diagnosed invasive, nonmetastatic breast cancer were recruited and interviewed to collect sociocultural and health care process data; clinical data were collected from charts. Of the sample (n = 359), 270 had HR(+) disease. Primary analysis focused on those with HR(+) node-negative disease (n = 143); secondary analyses included node-positive women. Logistic regression models evaluated factors associated with receipt of RS testing and chemotherapy.

RESULTS

Among women eligible for the 21-gene assay, 62 patients [43%] received RS testing. In multivariable analysis, older age (odds ratio, 1.04 per 1 year increase; 95% confidence interval, 1.01-1.08) was associated with RS testing after adjustment for covariates. Chemotherapy use was 23%. In multivariable analysis, positive attitudes about chemotherapy and greater risk of recurrence were associated with chemotherapy use (P < .05).

CONCLUSION

Patterns of genomic testing might vary according to age. Efforts to understand factors associated with low testing rates will be important.

Traditional roles in a non-traditional setting: genetic counseling in precision oncology

Next generation sequencing technology is increasingly utilized in oncology with the goal of targeting therapeutics to improve response and reduce side effects. Interpretation of tumor mutations requires sequencing of paired germline DNA, raising questions about incidental germline findings. We describe our experiences as part of a research team implementing a protocol for whole genome sequencing (WGS) of tumors and paired germline DNA known as the Michigan Oncology Sequencing project (MI-ONCOSEQ) that includes options for receiving incidental germline findings. Genetic counselors (GCs) discuss options for return of results with patients during the informed consent process and document family histories. GCs also review germline findings and actively participate in the multi-disciplinary Precision Medicine Tumor Board (PMTB), providing clinical context for interpretation of germline results and making recommendations about disclosure of germline findings. GCs have encountered ethical and counseling challenges with participants, described here. Although GCs have not been traditionally involved in molecular testing of tumors, our experiences with MI-ONCOSEQ demonstrate that GCs have important applicable skills to contribute to multi-disciplinary care teams implementing precision oncology. Broader use of WGS in oncology treatment decision making and American College of Medical Genetics and Genomics (ACMG) recommendations for active interrogation of germline tissue in tumor-normal dyads suggests that GCs will have future opportunities in this area outside of research settings.

Patients' understanding of how genotype variation affects benefits of tamoxifen therapy for breast cancer

BACKGROUND

CYP2D6 is a critical enzyme in the metabolism of tamoxifen and potentially a key determinant in breast cancer outcomes. Our study examined patients' beliefs about how the CYP2D6 genotype would affect their prognoses.

METHODS

Women enrolled in a pharmacogenomic clinical trial and on tamoxifen for prevention or treatment of breast cancer underwent CYP2D6 genotyping (EM = extensive, IM = intermediate, PM = poor metabolizing alleles). The informed consent said that the purpose of the trial was to examine effects of dose adjustment based on genotype, but that clinical benefits were uncertain. Our embedded sub-study surveyed 320 patients prior to receiving their genotypes. We experimentally manipulated 6 vignettes to describe hypothetical tamoxifen treatment (no or yes) and hypothetical genotype (EM, IM or PM). For each vignette, women gave their perceived recurrence risk (RR; 0-100%).

RESULTS

Women believed that genotype would not affect their RR if they did not take tamoxifen (p = 0.06). However, women believed that if prescribed tamoxifen, genotype would affect their RR (22% if EM, 30% if IM and 40% if PM, p < 0.001).

CONCLUSION

Women believed that extensive tamoxifen metabolizers had better prognoses, despite study materials stating uncertainty about any benefit. The rapidly changing nature of genomic science calls for caution when communicating clinical utility.

Understanding how breast cancer patients use risk information from genomic tests

We sought to examine how patients' treatment decisions incorporate potentially conflicting information from standard clinical indicators (e.g., tumor size) and genomic tests for breast cancer recurrence risk. Participants were 77 early stage breast cancer survivors who previously received genomic testing. They read six hypothetical vignettes that varied recurrence risk indicated by standard tests (low or high risk) coupled with the genomic test (low, intermediate or high risk). For each vignette, women reported their perceived recurrence risk and treatment preferences. Test results indicating high recurrence risk increased perception of risk and preference for chemotherapy (p < .001 for all). Perceived risk explained (i.e., mediated) the effect of test results on chemotherapy preferences. When test results conflicted, women gave more weight to genomic over standard test results. Hypothetical genomic test results had the intended effect of influencing women's perceptions of recurrence risk and interest in chemotherapy.

Racial differences in attitudes toward personalized medicine

BACKGROUND/AIMS

Patient concerns regarding personalized medicine may limit its use. This study assesses racial differences in attitudes toward personalized medicine, evaluating variables that may influence these attitudes.

METHODS

A convenience sample of 190 adults (≥18 years) from an academic primary care practice was surveyed regarding awareness and acceptance of personalized medicine, plus concerns and benefits regarding its use. Logistic regressions predicting awareness, acceptance and concerns were performed, controlling for race, gender, marital status, education, children, internet use, and self-reported discrimination.

RESULTS

The sample was 35% non-Hispanic white (NHW) and 34.7% male. More NHW participants expressed acceptance of personalized medicine than non-Hispanic black (NHB) participants (94.4 vs. 81.9%, p = 0.0190). More NHBs were concerned about the use of genes without consent (57.3 vs. 20.6%, p < 0.0001), sharing genetic information without consent (65.0 vs. 35.6%, p < 0.0001), discrimination based on genes (62.4 vs. 34.3%, p = 0.0002), and lack of access due to cost (75.0 vs. 48.0%, p = 0.0002). In logistic regressions, NHBs (OR = 7.46, 95% CI = 3.04-18.32) and those self-reporting discrimination (OR = 2.87, 95% CI = 1.22-6.78) had more concerns about the misuse of genes and costs associated with personalized medicine.

CONCLUSION

Racial differences exist in attitudes toward personalized medicine and may be influenced by self-reported discrimination. Further study to understand factors influencing the acceptance of personalized medicine could help encourage its use.

Association between genomic recurrence risk and well-being among breast cancer patients

Background

Gene expression profiling (GEP) is increasingly used in the rapidly evolving field of personalized medicine. We sought to evaluate the association between GEP-assessed of breast cancer recurrence risk and patients’ well-being.

Methods

Participants were Dutch women from 10 hospitals being treated for early stage breast cancer who were enrolled in the MINDACT trial (Microarray In Node-negative and 1 to 3 positive lymph node Disease may Avoid ChemoTherapy). As part of the trial, they received a disease recurrence risk estimate based on a 70-gene signature and on standard clinical criteria as scored via a modified version of Adjuvant! Online. \Women completed a questionnaire 6–8 weeks after surgery and after their decision regarding adjuvant chemotherapy. The questionnaire assessed perceived understanding, knowledge, risk perception, satisfaction, distress, cancer worry and health-related quality of life (HRQoL), 6–8 weeks after surgery and decision regarding adjuvant chemotherapy.

Results

Women (n = 347, response rate 62%) reported high satisfaction with and a good understanding of the GEP information they received. Women with low risk estimates from both the standard and genomic tests reported the lowest distress levels. Distress was higher predominately among patients who had received high genomic risk estimates, who did not receive genomic risk estimates, or who received conflicting estimates based on genomic and clinical criteria. Cancer worry was highest for patients with higher risk perceptions and lower satisfaction. Patients with concordant high-risk profiles and those for whom such profiles were not available reported lower quality of life.

Conclusion

Patients were generally satisfied with the information they received about recurrence risk based on genomic testing. Some types of genomic test results were associated with greater distress levels, but not with cancer worry or HRQoL.

Trial registration

ISRCTN: ISRCTN18543567

Comparison of EndoPredict and Oncotype DX test results in hormone receptor positive invasive breast cancer

Aim

Several multigene expression-based tests offering prognostic and predictive information in hormone-receptor positive early breast cancer were established during the last years. These tests provide prognostic information on distant recurrences and can serve as an aid in therapy decisions. We analyzed the recently validated reverse-transcription-quantitative-real-time PCR-based multigene-expression Endopredict (EP)-test on 34 hormone-receptor positive breast-cancer cases and compared the EP scores with the Oncotype DX Recurrence-scores (RS) obtained from the same cancer samples.

Methods

Formalin-fixed, paraffin-embedded invasive breast-cancer tissues from 34 patients were analyzed by the EP-test. Representative tumor blocks were analyzed with Oncotype DX prior to this study. Tumor tissue was removed from unstained slides, total-RNA was isolated and EP-analysis was performed blinded to Oncotype DX results.

Results

Extraction of sufficient amounts of RNA and generation of valid EP-scores were possible for all 34 samples. EP classified 11 patients as low-risk and 23 patients as high-risk. RS Score defined 15 patients as low-risk, 10 patients as intermediate-risk in and 9 patients as high-risk. Major-discrepancy occurred in 6 of 34 cases (18%): Low-risk RS was classified as high-risk by EP in 6 cases. Combining the RS intermediate-risk and high-risk groups to a common group, the concordance between both tests was 76%. Correlation between continuous EP and RS-scores was moderate (Pearson-coefficient: 0.65 (p<0.01).

Conclusion

We observed a significant but moderate concordance (76%) and moderate correlation (0.65) between RS and EP Score. Differences in results can be explained by different weighting of biological motives covered by the two tests. Further studies are needed to explore the clinical relevance of discrepant test results with respect of outcome.

Attitudes of patients with cancer about personalized medicine and somatic genetic testing

PURPOSE

Dramatic advances in genomic technology stand to revolutionize cancer care; however, little is known about patients' understanding and acceptance of personalized medicine and widespread genetic testing (GT).

PATIENTS AND METHODS

We conducted a formative, semi-structured interview study with a random sample of patients with lung, colorectal, and breast cancers to assess awareness of personalized medicine and GT and attitudes about somatic GT. Willingness to undergo GT was elicited through hypothetic scenarios.

RESULTS

Sixty-nine patients participated; 71% were women; 42% were black; median age was 59 years; and 42% had an education level ≥ college. We found that a majority of patients either were not aware of the term "personalized medicine" or defined it in unexpected ways. Although many patients identified relevant benefits of somatic testing (eg, informs treatment), many patients also expressed significant concerns (ie, psychological harm and discrimination). A majority of patients expressed a willingness to undergo somatic (predictive, 96%, prognostic, 93%) and germline (cancer risk without incidental information, 87%; cancer risk with incidental information, 81%; pharmacogenetic, 91%) testing; however, far fewer patients expressed a willingness to undergo full genome sequencing (62%). Reluctance was attributed to concerns over incidental findings, information overload, and the lack of a clear benefit.

CONCLUSION

Many patients relayed misunderstandings about somatic testing and a reluctance to undergo full sequencing; oncologists must carefully consider how they present testing to patients so that concerns over discrimination and psychological harm do not hinder test uptake. More work is needed to identify effective ways to communicate complex genomic concepts to patients and research participants.

Interest and attitudes of patients, cancer physicians, medical students and cancer researchers towards a spectrum of genetic tests relevant to breast cancer patients

The perspectives of patients and healthcare professionals towards breast cancer genetic tests that are becoming increasingly available is unexplored in Asians. We surveyed the interest and attitudes of 200 breast cancer patients, 67 cancer physicians, 485 medical students and cancer researchers towards three genetic tests, BRCA1/2 mutation, CYP2D6 genotype and Oncotype DX testing, using hypothetical scenarios. Approximately 60% of patients expressed initial interest in each genetic test, although the majority reversed their decisions once test limitations were conveyed, with <15% maintaining interest in each test. Cancer physicians were most likely to recommend BRCA1/2 mutation testing (73%) and least likely to recommend CYP2D6 genotyping (12%), while patients were more likely to choose Oncotype DX testing (28%) over CYP2D6 (21%) and BRCA1/2 testing (15%). Cost concerns, low educational level and lack of prior awareness of genetic testing were the main barriers against breast cancer genetic testing among Asian patients.

[Targeted chemotherapy for breast cancer: patients perception of the use of tumor gene profiling approaches to better adapt treatments]

The purpose of this review of the literature is to document how breast cancer patients perceive the use of tumor gene profiling approaches to better adapt treatments, and to identify the features of these approaches that may impact their clinical application. In general, the use of tumor genomic analysis was perceived by patients as an approach facilitating personalized medicine and received considerable support. Nevertheless, a number of confusions and worries about these practices were also identified. Improving the quality of provider/patient communications should enable patients to play a more active part in the decision-making about their treatment. This will ensure that those who agree to their tumor gene analysis have realistic expectations and sound deductions of the final result disclosure process.

Knowledge about genomic recurrence risk testing among breast cancer survivors

Genomic expression profiling of tumors is used to individualize early-stage breast cancer treatment. However, very little is known about patients' understanding of and desired information about these tests, such as Oncotype DX. We addressed these issues via a survey mailed to 130 early-stage breast cancer patients who received an Oncotype DX test result. The survey assessed understanding (14 items), information desired about genomic expression profiling tests, and if and where they sought information about Oncotype DX. Sixty-four surveys were returned. Overall, 54% of the knowledge items were answered correctly. Patients wanted education about genomic tests in many areas. Overall, 62% sought information about the test, primarily from the Internet (48%) and doctor or health care provider (31%). In sum, patients' misunderstanding of genomic tests abound, necessitating better educational efforts on behalf of health care systems to meet their needs for varied information through different communication channels.